Personality Disorder Under The Lens

Personality DisorderPersonality Disorder – not label, not put down, but no excuse for bad behavior: what is it then?


Attaching a mental health diagnosis to each other has become fashionable lately. Recently, statements in the press stating Trump is a narcissist, the neighbor is borderline, and the boss is bipolar are pretty commonplace.

In defense of my likable clients who suffered a great deal, it drives me mad because they are using mental health diagnosis as put downs or labels. I deem this behavior as something profoundly inappropriate and outright mean.

To make matters worse, the assumptions are blatantly false. Donald Trump’s inappropriate behavior is caused by lack of respect and bad conscious choices, not his narcissistic personality disorder.

It is true the other way around as well. Mental health diagnosis is not an excuse for bad behavior. Personality disorders might cause huge challenges in someone’s capability to accommodate his or her environment, but they are not excuses for disrespect or meanness.


Personality Disorders

… are diagnostic categories in which the individual has a longstanding , stable, relatively fixed pattern of thoughts, feelings and actions that permeates his or her whole life , including work and personal relationships, that deviates significantly from the expectation of the culture.

It differs from psychosis in that the person’s connection to reality is intact; there are no hallucinations or delusions that are present.

It differs from “depression, “anxiety” and “PTSD” in the extensive nature of the characteristics. Near the personality disorder, the person might suffer from the symptoms of depression or anxiety.


Causes of Personality Disorders

Behind them we assume there is genetic disposition with epigenetics that certainly plays a significant role and environmental stressors; especially early childhood abuse or neglect are contributors.

In the case of Antisocial Personality Disorder, James Fallon in his book “The Psychopath Inside” ,proposed the “Three legged Stool” theory that says: “… (1) unusually low functioning of the orbital prefrontal cortex and anterior temporal lobe including the amygdala, (2) the high-risk variants of several genes, the most famous being the warrior gene, and (3) early childhood emotional, physical or sexual abuse.


Type of Personality Disorders

The present Diagnostic and Statistical Manual of Mental Disorders discriminates 10 personality disorders and groups them in 3 clusters:

Cluster A: the “odd, eccentric” (and its features shortly)

Paranoid Personality Disorder: fears that everybody is out to get them.
Schizoid Personality Disorder: social detachment, in emotional “desert”.
Schizotypal Personality Disorder: odd beliefs, limited social capacity.


Cluster B: the “dramatic, emotional, and erratic” (Features shortly)

Antisocial Personality Disorder: no regards to others rights, no remorse, no morals.
Borderline Personality Disorder: intense, unstable emotions, polarized worldview, impulsive behavior.
Narcissistic Personality Disorder: grandiose self, entitlement, self-love.
Histrionic Personality Disorder: excessive but shallow emotionality, attention seeking.


Cluster C: the “anxious, fearful”

Avoidant Personality Disorder: avoiding social situations in order to protect themselves from feelings of inadequacy.
Dependent Personality Disorder: strong need to be taken care of by other, great difficulty to stand up for themselves.
Obsessive-Compulsive Personality Disorder: preoccupied with rules, regulations or rituals in order to control their anxiety.


It seems like a well defined system. Professionals can categorize the illnesses quite well, right? – Wrong. The criteria are vague, and fall into continuum. The “Box” is not as well contoured as you might think.


Diagnosing Personality Disorders

The Diagnostic and Statistic Manual of Mental Disorders gives a list of vague characteristics that are more or less typical of anybody in certain phases or situation of their lives.

Let’s take the example of Narcissistic Personality Disorder according to the DSM –IV:

“A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
(3) believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
(4) requires excessive admiration
(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
(8) is often envious of others or believes that others are envious of him or her
(9) shows arrogant, haughty behaviors or attitudes”

Before freaking out by diagnosing yourself as Narcissistic, it should be noted that everybody likes to feel important, admired, having power, brilliance, ideal love or feel entitled, have unreasonable expectations and so on.

We can place people on the continuum regarding these features. We consider it a personality disorder if it manifests itself in rigid and overwhelming emotional states or behaviors that interfere with the everyday functioning of the person.

This categorization raises other concerns as well. In order to diagnose Narcissistic Personality Disorder, the person needs to show at least 5 of these characteristics from this list. If another person shows another 5, is it the same illness? What if someone shows only 4? What if someone shows 3 from this list and 2 from let’s say the Borderline or the Antisocial Personality Disorder’s list? By the way, it’s quite common.

It is obvious that the category is not as unambiguous as people might think.


Treatment options

• Currently, there is no medication prescribed for personality disorder. However, pills can help to withstand the intense depression or anxiety bouts.

• Cognitive Behavior Therapies, as their names imply, are working on the conscious level and can achieve a lot by re-training the “Ego”. Famous among them is the Dialectic Behavior Therapy that manages stress syndromes, and teaches coping strategies for patients struggling with Borderline Personality Disorder. Furthermore, it has proven to lower the suicide rate among them.

• Long term – more often psychodynamic therapies are trying to unfold the unconscious connection in between the trauma/neglect they suffered and the present symptoms. Psychodynamic therapists believe that the symptoms are communications and unconscious attempts to resolve the issue and/or protect the person from the trauma they encountered. The therapy’s goal is multiplex: dealing with the trauma in the emotional level, bringing the unconscious associations into awareness, and modeling a healthy relationship with the therapist.


Prognosis varies…

1/ by person. No one can change somebody else but themselves. If the individual has the motivation, primarily by suffering enough, they might change. A real, severe personality disorder that had decades to develop needs more years of therapy to show some improvement.
2/ by severity. The more intense the symptoms, the bigger the challenge to change.
3/ by type of personality disorder.

Antisocial Personality does not react on psychotherapy because they do not have the interest/sensitivity for social clues that psychotherapy works with.

The Cluster A “odd type” disorders are quite stubborn, but at least they might have one trusting relationship with their therapist in the otherwise asocial “hostile” world.

Slow changes might be expected from the remaining types if every other condition including motivation, rapport with the therapist, and time for processing is in place.
4/ Occasionally, family members might suffer more from the symptoms than the client. They might benefit from consultations on what’s the most advantageous approach to handle the person suffering from personality disorder.


All in all:

personality disorders are deeply engrained, dysfunctional emotional, attitudinal and behavioral patterns of a person. Its emergence has a genetic and epigenetic background in interaction with the social environment. Its definition is somewhat vague, because of the different manifestations in different persons. Aiming for reasonable changes requires a huge dose of motivation as well as adequate time in committed therapy.


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